3. Quantify Impacts of Outdoor Recreation on Healthcare Outcomes and Costs

Better metrics and data are needed to support the business and policy case for an increased role of outdoor recreation in healthcare. The more data that can show how time spent outside improves health, the more credible the argument becomes. 

If the connection between nature contact and improvements in health can be linked to cost savings as well, the motivation to promote the use of the outdoors in healthcare will increase. 

The following suggestions, developed by workshop participants, address the type of data, evidence and information that needs to be collected, how organizations can collect it, and which partners might be best positioned to collaborate on its collection. 

What are the quantified impacts and metrics brought out during SHIFT that we can cite during our conversations with health stakeholders?

Different industries illuminate the health benefits of outdoor recreation from different perspectives. Each can buttress an argument; taken together, they can create a layered approach to underscoring the importance of outdoor recreation to public health.

Outdoor Recreation

  • The Outdoor Industry Association, the trade association of the outdoor industry, reports on the economic importance of the outdoor industry: “outdoor recreation is an economic powerhouse in the United States, each year generating $887 billion in consumer spending and 7.6 million jobs” 
  • Outdoor Recreation Participation Rates: The Outdoor Industry Association’s 2018 report indicated that almost half—49.0%—of the US population ages 6 and over participated in an outdoor activity at least once in 2017
  • The Outdoor Industry Association’s ConsumerVue provides macro-level insights on the U.S. outdoor consumer market that includes demographical snapshots of outdoor recreation use

Government

Governmental data from the federal, state, and local levels often serves as an important first step in understanding an issue. Every year, the government collects millions of data points which, taken together, paint a broad picture of a host of topics. This data can, and should, be used to identify the scale and scope of the outdoors and its health impacts, and should be used when identifying special populations in need of interventions (urban-rural outdoor access divides) and other topics important to both the health and outdoor fields. Sources of government data that can be used to better understand topics related to the outdoors and health include:

  • The US Bureau of Economic Analysis’ updated statistics from the Outdoor Recreation Satellite Account show that the outdoor recreation economy accounted for 2.2 percent ($412 billion) of current-dollar GDP in 2016.
  • Statewide Comprehensive Outdoor Recreation Plans (SCORPs) provide policy direction that allow state agencies to fulfill their recreation and preservation mandates. They are informed by large amounts of data, for example:
    • Oregon’s 2017 SCORP includes data on the number of times people engage in a particular outdoor recreation activity as well as the percent of the population that participates in an activity are estimated at the state scale. 
    • California’s upcoming 2020 SCORP will prioritize public health in parks, building on California’s 2015 focus for park access and park equity. This SCORP will reach a statewide audience, including health agencies, the Governor’s Office, and the National Park Service.
  • Demographics and psychographics, such as
  • Centers for Disease Control and Prevention:
    • Behavioral Risk Factor Surveillance System Survey: The CDC’s Behavioral Risk Factor Surveillance System (BRFSS) is a state-based system of health surveys that collects information on health risk behaviors, preventive health practices, and health care access primarily related to chronic disease and injury. For many states, the BRFSS is the only available source of timely, accurate data on health-related behaviors.
    • CDC mapping tools: Graphing and mapping program for interactively comparing geospatial data and statistics across regions
  • The US Department of Transportation’s Active Transportation Studies emphasizes the benefits of active transportation. “Investing in public transportation and bicycle and pedestrian facilities creates opportunities for people to exercise. This helps reduce obesity and the risks for developing costly chronic conditions such as diabetes and cardiovascular disease. Active transportation facilities are particularly important in low-income and minority communities, or communities with high percentages of new immigrants.”
  • The Bureau of Transportation Statistics indicate that Americans total 1.3 trillion person-miles of long distance travel a year on about 2.6 billion long distance trips. 56 percent of long distance trips are taken for pleasure — vacations, sightseeing trips, visiting friends or relatives, outdoor recreation
  • Bikeable connectivity analyses, such as 
  • Proximity analyses, such as 
  • US Forest Service’s National Visitor Use Monitoring Program produces estimates of the volume of recreation visitation to National Forests and Grasslands as well as descriptive information about that visitation, including activity participation, demographics, visit duration, measures of satisfaction, and trip spending connected to the visit.
  • National Parks and State Parks visitation rates
    • In 2017, the National Park Service received nearly 331 million recreation visits.
    • State parks represent less than 2% of the total outdoor recreation estate, but over 30% of all visitors at state and federal outdoor recreation areas. In 2017, there were over 807 million visitors to America’s state parks. Over 90% of all state park visitors were day-time users.

Research

Researchers in institutions around the country are studying the impacts of nature contact on human health and wellbeing. States that have outdoor recreation leadership positions can work with research institutions in their jurisdictions that have already embarked on such studies, or begin conversations with relevant institutions to encourage exploration of the topic. Examples of relevant research includes:

Healthcare

Within the $3.2 trillion healthcare industry, social determinants of health are increasingly seen as levers for cost savings. Mergers that are resulting in larger-than-ever health care systems and the advent of new health-care settings and health-care delivery systems are just two of the converging trends in a dramatically changing healthcare system. 

Within this change, outdoor recreation has a significant role to play in the treatment and management of chronic diseases such as diabetes, heart disease, obesity, and mental anxiety. It also has the potential to be a cost-effective component of comprehensive health care. 

The future of medicine in the US will focus on changing patient behavior, which contributes up to 40% of health and wellness. There is an opportunity to bring together advocates, health care networks, the scientific community, and others to advance nature and health as part of the future of healthcare in the country. 

At the same time, although the empirical evidence for nature’s positive impact on health is mounting, large-scale studies and funding are necessary to attain critical mass for the adoption of nature as a social determinant of health.

Companies such as Solera Health, which integrate highly fragmented programs and services into one high-access, lower cost network to prevent and manage chronic health conditions paid through medical claims, represent what could be part of a near-term solution for integrating nature as part of lifestyle choices into a comprehensive approach to health care, especially for chronic disease. Other resources include the following:

  • U.S. Surgeon General Vivek H. Murthy’s 2015 Call to Action on Walking is based on definitive medical evidence that moderate physical exercise boosts your health and cuts your chances of diabetes, dementia, depression, colon cancer, cardiovascular disease, anxiety and high blood pressure by 40 percent or more
  • The American Public Health Association has a number of policy statements and papers, such as the ones found here, that contain data on nature contact
  • The American Heart Association’s Active Transportation Policy Statement promotes active transportation — the opportunity to bike, walk, or roll to work, school, or around the community — through policy, systems and environmental change as one of the leading evidence-based strategies to increase physical activity across the lifespan.

Advocacy Groups

Organizations across the country that are advocating for physical activity outdoors often cite data to back up their positions. Outdoor recreation stakeholders can create strategic alliances with such organizations, which in turn can provide access to evidence that can be cited during conversations with health stakeholders.

  • The National Parks and Recreation Association’s report, 5 Key Trends in Parks and Public Health,notes that “Decades of medical research attest to the preventive and curative effects of increased fitness—particularly outdoor exercise and walking-oriented lifestyles—on children and adults” 
  • The Outdoor Industry Alliance provides “5 Tools You Can Use to Advocate for Outdoor Recreation” 
  • Community Health Solutions works across sectors with associations, foundations, nonprofits, public agencies, and business organizations helps organizations create positive impact for the people they serve. Their 3-4-50 frameworkis a community health improvement strategy based on evidence that three health behaviors—one of which is sedentary lifestyle—elevate risk for four chronic conditions that together cause more than fifty percent of deaths

What additional research or metrics do we need to insure the health sector adopts outdoor recreation as a health intervention?

Data Aggregation

On Oct. 18, in Jackson, WY, at the Researchers’ Meeting at The 2018 SHIFT Festival, a broad cross-section of professionals from the research, health care, conservation, land management and outdoor recreation communities discussed the 2017 Frumkin et al research agenda on nature contact and health. Participants noted that while the healthcare insurance industry uses research to inform their reimbursement standards, large population studies on the connection between time spent in nature and human health are difficult to find.   

That being said, data relevant to the Outside Rx movement is available. Participants noted a number of needs that can be filled by existing data. For those needs that are not addressed, participants recommended that the Frumkin et al research agenda, as well as the additional clarifying questions identified during SHIFT’s Researchers’ Meeting, be used to focus state efforts to aggregate data.

Additional recommendations were as follows:

Share visitation and usage data

The Parks Prescription Report from the Golden Gate Institute notes that “Parks and public lands are an underutilized healthcare resource. For example, just 20 percent of the 300 million visitors to America’s national parks cite active recreation as the main reason for their visit. At the same time, parks and public lands represent enormous acreage—nearly one in every five acres of the United States is federal land that is open for public use.”

Outdoor recreation visitation and usage data from national, state, and regional regional parks, active transportation plans and insurance companies provide opportunities to advocate for outdoor recreation as a public health benefit, but only if that information is shared between offices and states. Such sharing requires a central repository of information. For this reason, participants recommended the creation of an information “hub” that in turn could promote the widespread dissemination of metrics and data that in turn is key to the advancement of nature as a social determinant of health.

Highlight Successes 

Participants also noted the need to highlight examples of the positive impacts of outdoor recreation to insure the health sector takes it seriously as an intervention model.

  • The study, Inadequate Physical Activity and Health Care Expenditures in the United States, published by the National Center for Disease Control, of 51,165 adults age 21 years or older (excluding those who were pregnant or who reported being unable to do physical activity), reported an average total annual health care expenditures per year of $1.05 trillion (for the sample weighted to the U.S. population). After adjusting for the main covariates, the mean annual expenditure difference per capita for inactive adults compared to active adults was $1,437 (percent difference: 29.9%) and for insufficiently active compared to active adults was $713 (15.4%).
  • A 2000 CDC report noted that “The potential savings if all inactive American adults became physically active could be $29.2 billion in 1987 dollars, or $76.6 billion in 2000 dollars.” 
  • The study, “Economic Analysis of Outdoor Recreation in Washington State,” by the Washington State Recreation and Conservation Office, looks at the health as well as the economic benefits of hiking, biking, and walking. The study notes that “using recreation to stay active reduces public and private health care expenses. The average difference in annual medical care costs between active and inactive people is $250 for adults under 65 years of age and $500 for those over 65 years of age. One study estimated about $64 million in total medical care cost savings being attributable to the Seattle Park system.”
  • First Descents’ research partnerships with the Keck Graduate Institute and the University of Michigan found that outdoor adventure programming can lower rates of depression, increase self-esteem and body image, and improve participants’ ability to cope with cancer and its psychosocial effects.

What additional research or metrics do we need regarding equitable access to insure the health sector takes recreation seriously as a strategy?

Access for all

Access manifests itself through financial resources and transportation as well as physical access. According to the 2009 Transit to Trails report, “Diversifying access is important to build support for parks and green space in urban and rural areas.” The paper, Leisure Constraints Relevant to Racially and Ethnically Diverse Groups, notes that limited access to resources is a commonly cited constraint among racially and ethnically diverse groups. 

  • In Stodolska and Shinew’s 2014 study on constraints that affect Latinos’ participation in recreation and physical activity, residents commented that their poorly maintained parks had “jogging trails full of potholes, dilapidated playground equipment, trash, lack of water fountains and unsanitary restrooms” (p. 321). Residents of underresourced communities noted that lack of access to well-maintained parks affected their recreation participation
  • Powell, Slater, and Chaloupka’s 2004 examination of the association of race, ethnicity, and socioeconomic status with community-level recreation and physical activity settings (i.e., sport areas, green spaces, bike paths) showed that African Americans and individuals of “other” races were less likely to have access to community recreation resources
  • The 2006 paper, Active Living and Social Justice: Planning for Physical Activity in Low-Income, Black, and Latino Communities, notes that “planning for active living must especially address low-income, Black, and Latino communities, where obesity and related health risks are greatest and resources least available”
  • According to the 2009 Transit to Trails report, “The Angeles National Forest provides 78% of the public space in the Los Angeles region, and lies within an hour’s drive of most of Los Angeles, but few people of color go there. Recreation is the predominant use of the forests in Southern California. Yet only 1% of the visitors to the forest are black, and only 11% are Hispanic. Zero percent of the visitors to the wilderness areas of the Angeles National Forest are black.”

Data on equity and underserved communities

The fact that time spent recreating outdoors improves individual and community health is established. Access to and the distribution, quality and safety of these spaces is, however, not equitable.  

What additional research or metrics do we need regarding proximity to and accessibility of outdoor recreation to insure the health sector adopts recreation as a health intervention?

How far away citizens are from recreational opportunities, as well as how safe they perceive those spaces to be, impacts their usage of those spaces and therefore their health. As The Trust for Public Lands notes, “Close-to-home opportunities to exercise and experience nature are essential for our physical and mental well-being.” Participants agreed that it is important to highlight research and data that in turn underscores the argument for every citizen to have equitable, safe access to spaces that are close to where they live.

  • A statewide study done by California parks department in 2009 found that 74% of people who went to parks walked for fitness or pleasure, and 70% of respondents spent over 30 minutes being physically active in parks. The top cited factors that were perceived to limit their level of physical activity was access to facilities and amenities
  • The study, “Why Your ZIP Code Matters More Than Your Genetic Code: Promoting Healthy Outcomes from Mother to Child,” found that in cities across America, average life expectancies in certain communities are 20 to 30 years shorter than those mere miles away, and that health disparities can be linked to lack of access to green spaces and outdoor recreation opportunities
  • The Trust for Public Land’s ParkScore® index measures how well the 100 largest U.S. cities are meeting the need for parks. Using an advanced GIS (Geographic Information System), ParkScore® provides in-depth data to guide local park improvement efforts. Their mapping technology identifies which neighborhoods and demographics are underserved by parks and how many people are able to reach a park within a ten-minute walk

Local and regional data to help pitch project ideas

  • Targeted data on usage, access, quality, and safety of green spaces can become an invaluable tool to help justify funding and programming
    • In 2005, the Los Angeles Public Health Department did a study on preventing childhood obesity and found that cities with less open areas set aside for parks, recreation areas, and wilderness areas had higher rates of childhood obesity. It was estimated that only 30% of Los Angeles residents lived within a quarter mile of a park. Obesity was higher among lower income neighborhoods, whose residents often reported not having access to a safe place to recreate
    • The 2007 report, Many Pathways from Land Use to Health, studied residents in King County, Washington and found that “a 5% increase in walkability [was] associated with a per capita 32.1% increase in time spent in physically active travel [and] a 0.23-point reduction in body mass index [BMI].” Reducing the average BMI by one point would save the American healthcare system $27.9 billion annually.
    • The NRPA’s tool Park Metrics allows park and agencies department to build customized reports that allow for comparisons with peer agencies. Park and recreation professionals can use this benchmark data to gain more funding support, improve operations and better serve their communities.

Guidelines to improve access to outdoor recreation opportunities

  • The Oregon Public Health Institute’s Health and Outdoor Education Guideline is designed to increase access to, and use of, outdoor areas, particularly among communities of color, people with disabilities, and low-income people in rural and urban areas of Oregon
  • The NRPA’s Safe Routes to Parks Action Framework provides guidance on evidence-based strategies that create safe and equitable access to parks for all people. It includes case studies, sample policy language and fact sheets designed to help agencies implement best practices.
  • The Gehl Institute’s Inclusive Healthy Places report provides a framework for policy makers and community leaders to mindfully design, implement, and maintain public spaces as a way to improve health equity
  • New York City’s Active Design Guidelines present cities with guidelines to designing urban environments that encourage “active transportation and recreation” through urban planning
  • The City Park Alliance’s Active Parks, Healthy Cities distills the findings of the National Study of Neighborhood Parks into four major recommendation categories: Programming, Design, Marketing and Outreach, and Measuring Park Use
  • The National Park and Recreation Association, in the paper From Sea to Shining Sea: Improving Equitable Access to Public Lands for All, provides guidelines for improving equitable access to public lands

Impacts

Participants noted the following additional research or metrics regarding the impacts of outdoor recreation that can help expedite the adoption of recreation as a health intervention.

Conservation, Environmental Appreciation, and Mental Health

  • Resources that focus on the mental health benefits of conservation and the outdoors include the following:
    • The 30 Days Wild study conducted by the University of Derby [UK] showed that there was a scientifically significant increase in people’s health, happiness, connection to nature and active nature behaviors that lasted for months after the study had been complete
    • What are the Benefits of Interacting with Nature? looks at the empirical evidence that interacting with nature delivers measurable benefits to people
    • Environmental Stewardship: A Conceptual Review and Analytical Framework proposes a clear definition and comprehensive analytical framework to strengthen our ability to understand the factors that lead to the success or failure of environmental stewardship 

Health outcome assessments for outdoor recreation programs

Outdoor Education data 

Recreational impact monitoring 

  • Wilderness Connect’s Recreation Site Monitoring Toolbox provides an overview of recreation site monitoring in wilderness areas
  • Yosemite National Park’s Visitor Use and Impact Monitoring Program was created to fulfill the mandate of the Wild and Scenic River Act to “protect and enhance” the unique values of the Merced and Tuolumne Rivers, which were designated as Wild and Scenic in 1987 and 1986 respectively
  • This Recreation Impact Monitoring Analysis report describes a recreation impact assessment protocol developed for Glacier Bay National Park, Alaska. It includes an analysis of historical campsite assessment data, a summary of data collected during development of the revised protocol, recommendations for implementation and all procedures necessary to conduct a baseline recreation impact assessment in coastal areas of Glacier Bay National Park

How can the outdoor industry and health and wellness stakeholders work together to help generate the research and metrics necessary to promote the adoption of outdoor recreation as a health intervention by the healthcare sector?

Address data gaps

The 2017 Frumkin et al research agenda identified seven areas of focus critical for the provision of evidence that in turn will be necessary for public health interventions. The authors concluded that although significant evidence regarding nature contact and its range of human health benefits was already available, much remained unknown. They furthermore proposed that a robust research effort, guided by a focus on key unanswered questions, had the potential to yield high-impact, consequential public health insights.

At SHIFT’s 2018 Researchers’ Meeting, the discussion of the seven domains generated extensive conversation regarding details that participants felt needed additional clarification. It is recommended that state leadership positions in outdoor recreation use the seven domains and the questions that remain to be clarified as guidelines for efforts to address data gaps and create an action plan to address them.

Data Sharing

Given the limits of available data, as well as the lack of a central repository for metrics and evidence relative to the health benefits of outdoor recreation, it is recommended that state offices of outdoor recreation adopt a single site, such as the Confluence of States website, and use it to share information and best practices and communicate information effectively among stakeholders.

Key allies the outdoor industry needs to work with on the aggregation and sharing of data to insure the health sector adopts outdoor recreation as a health intervention

Participants agreed that outdoor recreation leadership positions will benefit by developing partnerships with sectors whose priorities regarding the aggregation and sharing of data complement their own. Participants noted a few such key allies below.

Government

Partnering with other governmental agencies to gather evidence that in turn can be used to advance shared priorities, initiatives and programs is both logical and helpful. Key allies include: 

  • Regional Planners, whocan be valuable partners because of their influence with regional land usage and community programs. 
  • Land Managers
  • Parks and Recreation Departments
    • California State Park’s The Health and Social Benefits of Recreation offers a compilation of research documenting the physical, mental and social benefits of parks and recreation that is important for local and state park and recreation service providers in gathering support for their programs.
    • In 2010, The Minneapolis Park and Recreation Board began a research partnership with the University of Minnesota to investigate the outdoor leisure time activity needs of different family types and the impact of neighborhood park design on family health and well-being.
  • Departments of Transportation
    • The U.S. Department of Transportation’s Health Performance Metrics are measures that can be used to assess the performance of a transportation plan or project against select health-related goals. Among other things, use of the metrics can result in health benefits by addressing chronic disease (e.g., asthma, diabetes, heart disease), improving equity and increasing physical activity
    • The Transportation Alternative funding has made a lot of improvements in Tennessee. Communities across the Volunteer State have built sidewalks, constructed bike and pedestrian trails, renovated historic train depots and other transportation related structures. 
  • The CDC has long been a proponent of outdoor recreation as a health solution, particularly for chronic diseases 

Health Groups

Entities the purview and focus of which is public health represent organic partners for stakeholders in the outdoor recreation community.

Research

Key allies the outdoor industry needs to work with in the research sector to insure the health sector adopts outdoor recreation as a health intervention include the following:

  • Universities and Research Centers
    • The National Parks Service currently has a partnership with Cooperative Ecosystems Studies Units to provide research and technical assistance for natural and cultural resource management. State offices could potentially set up a similar partnership with local educational institutions to gather data, inform their decisions, and have concrete evidence to garner financial support from healthcare organizations
    • Penn State University’s Recreation and Protected Areas Lab has ongoing studies surrounding outdoor recreation in national forests and visitor usage.
    • Cornell University’s Nature Rx campaign prescribes time outdoors in nature for students. The program encourages students to appreciate and utilize time in their natural environment as a way to reduce stress and improve their own physical and mental health
    • In a creative partnership between parks and academia, the City of Allentown (PA) Parks and Recreation sought to better understand its users. With funding from the Pennsylvania Recreation and Park Society, the city worked with Penn State University to connect the city into a recreational destination
    • At UCSF Benioff Children’s Hospital Oakland, The Center for Nature and Health engages in Translational Research to understand how more public health and health care systems can use in nature in healing; provides clinical care for vulnerable populations; builds the field of nature champions by developing training modules, replicable protocols, and other tools that can be used by public health departments and medical practitioners; and advocates for nature as a public health priority
    • Nature for Health at University of Washington is launching a robust program of research to generate answers to questions related to nature contact. The initiative, which seeks to further the understanding of the impacts of nature on human health, has the potential to shape policies, programs and the landscapes we inhabit. Nature for Health currently focuses on five sectors—veterans, children, the elderly, healthcare providers and underserved populations.
    • In Louisville, KY, The Envirome Institute promotes a new, interdependent vision of health, supports research on the effects of the environment on health, and promotes holistic scholarship, locally and globally.
    • The 2011 opening of the new Walter Reed National Military Medical Center (WRNMMC) represents an era of holistic medicine in the U.S. military health system. Its whole-person approach to patient-care and state-of-the art facilities were informed by the Epidaurus Project, an initiative spearheaded by Institute of Integrative Health Scholar Fred Foote, MD to create a model healing environment for Wounded Warriors of the Iraq War as well as other service members. As part of the Project, the Green Road Project will use three of the Epidaurus metrics to evaluate the healing effects of spending time in nature
    • The HOPE (Healthy Outdoor Play and Exercise) Lab at Appalachian State University is working on projects related to ParkRx in NC. 
    • The University of Utah offers anOutdoor Recreation Studies (ORS) emphasis from within its College of Health.

Technology Industry

The technology industry represents an untapped ally in the movement because of its ability to track, capture and record data using tools that are ubiquitous in society.

  • Fitbit, a global wearables brand, partners with Humana Inc., a health and well-being company, to help members adopt and implement healthy behaviors to help prevent and manage chronic conditions. 
  • Fitbit Care is a connected health platform that maximizes health outcomes across the spectrum of care, from wellness and prevention to condition management and complex care, by helping drive behavior change and improving care team collaboration.
  • Strava is a social fitness network that is primarily used to track cycling and running using GPS data. Strava can be integrated with the iOS Health App, through which it can receive and send data such as activity type, distance, time, and calories. 
  • The Health app on iPhone, Workout app on Apple Watch, and Activity apps on both are separate and have distinct functions, but can work together to offer a detailed picture of your overall health.
  • Garmin offers a suite of health care products, from corporate wellness programs to patient monitoring

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